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Recurrence of hyperprolactinemia after withdrawal of dopamine agonist therapy
A 32-year-old woman had imaging to evaluate headache. The MRI incidentally found “fullness of pituitary possibly representing pituitary microadenoma but without discrete lesion seen.” Her primary care practitioner found slightly high prolactin of 32 ng/mL (3-27 ng/mL). She denied menstrual irregularity. Thyroid-stimulating hormone and other laboratory studies were normal. Nevertheless, her primary care practitioner initiated dopamine agonist which she had been receiving for three years until she came to see me.
A repeat MRI did not show any abnormality. She was on both oral contraceptives as well as selective serotonin reuptake inhibitor at the time of the initial prolactin.
She asked me: “Do I need to be on cabergoline forever?”
We decided to stop therapy and monitor. Now, one year later, her prolactin remains normal. I would not have begun dopamine agonist initially but instead would have repeated prolactin and followed by observation.
How often can patients with hyperprolactinemia treated with dopamine agonist have therapy stopped and be normoprolactinemic afterward?
A recent meta-analysis published online in the Journal of Clinical Endocrinology & Metabolism evaluated the effects of stopping dopamine agonist in patients with hyperprolactinemia and prolactinoma. The authors found that hyperprolactinemia recurs in a substantial portion of patients. The greatest chance for long-term success seemed to be in those with idiopathic hyperprolactinemia (32%) compared to microprolactinoma (21%) and macroprolactinoma (16%). Treatment success was also associated with being assigned therapy for two or more years.
If a patient with hyperprolactinemia has been well controlled on long-term, low-dose therapy, I often discuss treatment withdrawal, particularly in those with microprolactinoma or hyperprolactinemia without pituitary abnormality.
One exception might be a woman desiring fertility. Some data suggest that high prolactin in the absence of menstrual abnormality could be associated with decreased fertility. In that situation, I might continue therapy if it is well tolerated and especially if the patient has had previous fertility issues.
Of course, if there is another reason for hyperprolactinemia, such as medication or hypothyroidism, we always address that before making recommendations on whether dopamine agonist should be initiated or continued.
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